Healthcare Provider Details

I. General information

NPI: 1417007139
Provider Name (Legal Business Name): ERIC WYATT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 NW 31ST ST
LAWTON OK
73505-6100
US

IV. Provider business mailing address

104 NW 31ST ST
LAWTON OK
73505-6100
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-2121
  • Fax: 580-250-5183
Mailing address:
  • Phone: 580-536-2121
  • Fax: 580-250-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number19537
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: